Guidance: Service Authorization and Claims Submission Information

The Authorization Requirements Unchanged section was added to this guidance March 27, 2020.

In response to the state of emergency related to coronavirus (COVID-19), a number of the Ohio Department of Developmental Disabilities’s (DODD) standard requirements for authorization for waiver services have been lifted temporarily.

DODD acknowledges that these temporary changes are a significant deviation from the way waiver services have been authorized in the past. The department is taking these steps in an effort to eliminate potential barriers to the authorization and delivery of needed services.

Key Changes to Existing Requirements

Services may be authorized through electronic means, such as via email or telephone, and documented in case notes for the person with disabilities receiving services. While it is still required that needed services are authorized through the person-centered team process, the face-to-face requirements and original signature requirements are suspended.

Services do not have to be entered into the Cost Projection Tool (CPT) area of the Medicaid Services System (MSS) and pushed to the Payment Authorization for Waiver Services (PAWS) system. There is no requirement for county boards of developmental disabilities to retroactively add services authorized during the state of emergency to these systems.

Prior authorization from DODD is not required for services that exceed the person’s Ohio Developmental Disabilities Profile (ODDP) funding range during this time.

Services delivered throughout the state of emergency will be submitted through the Medicaid Billing System (eMBS) for review and payment through the regular process. Changes have been made to eMBS to accommodate requirement changes listed above.

DODD is providing assurance to county boards and providers that there is no expectation that CPT in MSS and PAWS systems will accurately reflect authorized services during the state of emergency. Additionally, DODD is not asking for retroactive updates to be made to any of these systems nor retroactive requests for prior authorization after the state of emergency has ended.

County boards may continue to update these systems should they choose to do so; however, it is important to note that these systems may not be flexible enough to support the authorization of the service levels needed by people with disabilities during this state of emergency. It is important that system constraints are not treated as a barrier to the authorization and delivery of needed services.

After the state of emergency has concluded, DODD will make any needed changes to these systems to isolate service authorization and claims activity during the state of emergency. DODD is assuring county boards and providers that the agency will support the likely disconnect between service authorization within the department’s system and claims payment in any post-review activities related to this period.

Authorization Requirements Unchanged

This section was added to this guidance March 27, 2020.

Any services billed and paid in excess of what is authorized are subject to recovery.

It is important to remind providers, as well as county boards, that there have been no exceptions made to the requirements that services must be both necessary to ensure health and safety, as well as authorized through the person-centered planning process. System constraints should not be treated as a barrier to the authorization and delivery of needed services.

DODD strongly encourages county boards to continue to authorize services through the most expedient means available and to ensure that providers have confirmation of the frequency, scope, and duration of services authorized. County boards may continue to utilize DODD’s PAWS system to the extent that it can accommodate needed changes. If the county board is not able to use the PAWS system during this state of emergency, written confirmation of service authorization through email to the provider is recommended.

DODD plans to monitor spending throughout the state of emergency and also to conduct significant analyses after the state of emergency has concluded.

DODD will work closely with county boards to confirm that increases in spending that are revealed after the state of emergency has concluded were appropriately authorized. If incidents of billing for services that were not authorized by the county board are identified, providers will be required to submit adjustment claims to DODD, so that the payments for those claims can be recovered.

Failure of the provider to comply with the claims adjustments opportunity will result in further action being taken, up to and including referral to appropriate compliance and regulatory agencies.

Information and Resources

DODD has set up a dedicated web page for department communications and links to helpful resources that will advise people with disabilities, their families, service providers, direct support professionals, county boards of developmental disabilities, and the community at large.

For specific questions about COVID-19 and additional information and resources, DODD urges you to use the Ohio Department of Health’s call center. Call 1-833-4-ASK-ODH (1-833-427-5634), or visit coronavirus.ohio.gov.